25
Alcohol and Road Accidents
A Fabbri Dipartimento Emergenza-Urgenza Accettazione,
Ospedale Morgagni-Pierantoni, Azienda Unità Sanitaria Locale di Forlì, Italy
G Marchesini Dipartimento di Medicina Interna e Gastroenterologia,
Università degli Studi di Bologna, Italy
A Vandelli Dipartimento Emergenza-Urgenza Accettazione,
Ospedale G.B. Morgagni, Azienda Unità Sanitaria Locale di Forlì, Italy
Road accidents represent an enormous burden to society
and an immeasurable human cost. During the last 30 years
the overall volume of traffic has tripled and injuries after
road accidents are today a major public health problem.
Road accidents are predictable and preventable and many
interventions may reduce the most severe events. The
Commission of the European Union has recently proposed
an action to halve the number of deaths after road accidents
by 2010; all parts involved in road safety are committed to
take action in this direction. Alcohol is one of the most
important risk factors, being responsible for about 10,000
deaths each year in the European Union. The number of
fatalities might be reduced by 5–40% by stopping driving
with blood alcohol concentration over the legal limits of
0.5 mg/ml. Several factors may add to alcohol to determine
Tumour necrosis factor
the risk of road accidents and the severity of injury. The
most important are high speed, male sex and young age,
driving inexperience, fatigue, use of psychotropic legal and
illicit drugs, weekend night, misuse of seat belts or helmets.
Alcohol may impair the patho-physiological response to
injury, but the putative mechanisms are not definitely proved.
Also at low concentrations, it may influence both the diag-
nostic process and the final outcome of patients after injury.
At first evaluation, the degree of injury may be overestim-
ated in intoxicated patients, prompting a greater number of
diagnostic manoeuvres and invasive procedures. Alcohol
positive patients are more likely to need intensive care, sur-
gery, blood transfusion, and longer hospital stay, because of
more severe acute medical complications (infections, respi-
ratory failure and shock). In patients with positive blood
alcohol concentrations previously unsuspected injuries are
more likely to be diagnosed during follow-up. The recidi-
vism rate for road accidents is larger in patients with chronic
alcohol abuse, independently of the driver or passenger sta-
tus. Physicians who provide care to injured patients after
road accidents have an important role in preventing alcohol-
related injury and death. They can refer patients suspected
for drinking and driving for treatment after a road acci-
dent, when their motivation is definitely increased. Brief
Authors are indebted to the librarian, Dr Maria Grazia Camelli,
Biblioteca Tecnico-Scientifica Azienda USL Ravenna, Italy, for her
competence and helpful support in the literature search.
Comprehensive Handbook of Alcohol Related Pathology Volume 1
ISBN: 01256 43713
Set ISBN: 01256 43705
interventions in the emergency room decrease alcohol con-
sumption and decrease the incidence of further events
caused by driving under the influence of alcohol.
Abbreviations
CI Confidence interval
ED Emergency department
EU European Union
IL Interleukin
NISS New Injury Severity Score
OR Odds ratio
ROC Receiver operator characteristic
TNF-
Introduction
Road traffic injuries are a major public health problem,
being the 10th cause of death, the ninth leading contrib-
utor to the burden of disease world-wide, and the third
cause of disability-adjusted life years lost (Murray and
Lopez, 1996; Krug, 1999). They constitute a growing
problem, with 1,171,000 deaths annually with an estim-
ate of 40% increase from 1990 (5.1 million) to 2020
(8.4 million). In 1998, developing countries accounted
for more than 85% of all deaths and for 96% of children
deaths due to road traffic crashes (Krug, 1999).
Historically, road accidents were scarcely considered,
and related injuries and deaths were seen as accidents
or random events. Today, we definitely know that they
are predictable, preventable, and that several interven-
tions may reduce the most severe events.
Urbanization and motorization of developing coun-
tries and lack of prevention programmes in the public
health area account for the rising number of events
(Peden et al., 2001). A lot of prevention activities have
been planned by the World Health Organization in
the area of road traffic injuries, and policies for the
control and the prevention of events have been specifi-
cally considered in relation to different injury profiles.
Copyright © 2005 Elsevier Ltd
All rights of reproduction in any form reserved
310 General Aspects of Pathology
In the European Union (EU), road accidents are
estimated to be over 1,300,000 per year, the main
cause of death in subjects under 45 years; their cost
totals €160 billions per year, approximately 2% of EU
Gross National Product. With over 40,000 victims per
year, one might speculate that an avoidance of a single
fatal accident would save up to €1 million. There is,
therefore, an economic justification for taking meas-
ures costing up to €1 million in order to save any single
life (European Commission, 2001).
The main characteristics and trends of road accidents
largely differ from one country to another, due to a
rapidly increasing number of cars in certain member
states. The total number of fatal accidents is conversely
decreasing and high-risk events are those involving pedes-
trians, cyclists, motorcyclists, young adults, and elderly
patients. In last few years, a multidisciplinary 5-year
global strategy has been put forward, aimed at halving
the number of road deaths by 2010, by means of eco-
nomic, social, educational, and transport policies (Peden
et al., 2001). However, there is an enormous gap between
the Member States’ ambitious declarations of intent and
the very modest provisions actually adopted, the princi-
ple of subsidiary too often being invoked as a means of
avoiding the adoption of specific measures at the EU level
(European Commission, 2003).
Safe driving requires that the subject has total mental
focus, physical coordination, and sound judgement.
Many factors can impair the mental and physical driv-
ing skill, including the adverse effects of medications
and the use of drugs, namely alcohol. Alcohol is indeed
one of the most important factors in road accidents. It
is a powerful drug with multiple deleterious effects on
the body. It exerts first a depressant effect, lasting a relat-
ively short time. This is followed by a weaker stimula-
tion on the central nervous system, persisting about six
times longer. Self-awareness of these two effects may
depend upon the degree of excitability of the central
nervous system at the time of alcohol ingestion, which
is, in turn, related to the environmental setting of drug
use and on the personality of the user. The initial effects
are mild, but may rapidly become dangerous, since
subjects under the effect of alcohol are not good judges
of how impaired they are.
Drinking and Driving in the
European Community
Thirty years of experimental and clinical studies sup-
port the conclusion that alcohol intake significantly
impairs driver performance and that there is a strict
relationship between blood alcohol concentration and
the risk of being responsible in a road accident.
The relationship between the amount of alcohol
intake and the resulting blood alcohol concentration is
largely variable. It mostly depends on absorption and
elimination rate, and on the volume of distribution
(the ratio between the total amount in the body and
blood concentration). The volume of distribution can be
estimated from age, sex, height, and weight, (Watson,
1988) and other individual variables, which are diffi-
cult to define. It is also hard to predict the total dose
raising blood ethanol concentration above the legal
limits for driving.
Legal limits, however, do not necessarily predict the
absence of neurological effects. Alcohol, also at low
concentration, may depress inhibitory neurons, turn-
ing an introvert subject into a garrulous exhibitionist.
Higher concentrations impair cerebellar functions,
causing slurred speech, poor hand–eye coordination, and
unsteadiness as concentrations, exceed about 0.35 mg/ml
(Johnson et al., 1982). With higher doses, sensory,
consciousness, and finally brainstem functions may
be depressed.
The performance of repeated tasks is particularly
impaired at any given blood alcohol concentration. In
addition, the performance further worsens in novel or
unexpected situations, although the impairment may
not be seen during routine tasks (Vogel-Sprott, 1992). A
review of 112 studies reports that certain skills necessary
to operate any type of motorized vehicle are impaired,
starting from near-zero blood alcohol concentrations
(Moskowitz and Fiorentino, 2000). At 0.5 mg/ml, most
studies report a significant impairment; by 0.8 mg/ml,
94% of studies show a definite impairment. A few abili-
ties are only impaired above 1.0 mg/ml.
An alcohol concentration of over 0.5 mg/ml pro-
duces an impairment of eye movements, eye resistance,
visual perception, reaction times, and driving perform-
ance tested in a simulator. A concentration as low as
0.2 mg/ml impairs the ability to divide attention
between two or more sources of visual information
(Moskowitz and Zador, 2000).
The relative risk of fatal crashes for drivers with posi-
tive blood alcohol concentration increases with increas-
ing alcohol levels, and the risk increases more steeply
for drivers younger than 21 years than for older drivers.
The risk of a fatal single-vehicle crash varies between
11-fold (for drivers 35 years) and 52-fold (for male
drivers aged 16–20 years) in patients with alcohol con-
centration between 0.8 and 1.0 mg/ml (Zador et al.,
2000).
Safe alcohol limits for driving remain difficult to
settle. Observational studies report that 1–5% of all
drivers have blood alcohol levels above their respective
maximum national alcohol limits. Such drivers are
more likely to be involved in road accidents, and
account for up to 20% of fatal and serious injuries,
and 25% of driver fatalities (Peden et al., 2001). It
may be estimated that over 10,000 road users die every

year because of drinking and driving. Ideally, they all
could be saved if drinking and driving could be elimi-
nated and all drivers were completely alcohol free
(Commission of the European Communities, 2003).
Simply by stopping driving with alcohol levels over
0.5 mg/ml (i.e. the limits for most European member
states), the number of fatalities might be reduced by
5–40% (Peden et al., 2001).
From a road safety perspective, the complete elimi-
nation of inappropriate drinking and driving would be
the optimum goal, but in the absence of public accept-
ance and adequate policies of enforcement a very low
blood alcohol limit would not be effective. In 1988, a
Commission of the EU brought forward a proposal for
harmonized blood alcohol legal limits at 0.5 mg/ml.
The large majority of member states have adopted this
proposal in their regional legislation and administrative
fines or additional sanctions were set for any concentra-
tion above this cut-off.
This policy is also part of general interventions to
reduce the dangerous effects of drinking and driving
supported by all member states. Most activities rely on
the combination of prevention, publicity, restrictive
blood alcohol limits, police enforcement, legal and
administrative sanctions (Peden et al., 2001). Annual
reports indicate that specific categories of drivers are
responsible for most drinking and driving problems.
They are typically either young male, inexperienced
drivers, who habitually drive in spite of very high blood
alcohol levels, or occasional drinkers intolerant to
alcohol, with low blood alcohol levels, sometimes even
below the legal limits. Reducing alcohol limits from
0.8 to 0.5 mg/ml could reduce road accidents not only
among young male drivers, but also among drivers
who habitually drive under the influence of alcohol,
the hard core of the problem. Reports from Australia,
Japan, the United States of America, and some European
countries show that any reduction of blood alcohol
limits, supported by effective enforcement, penalties,
and publicity, can significantly reduce drinking and
driving behaviour (Peden et al., 2001).
Today, only few member states of the EU retain a
maximum blood alcohol limit of 0.8 mg/ml and in the
case of the United Kingdom this limit was unchanged
since it was first set in 1967. In the United Kingdom,
inappropriate drinking and driving was achieved in
the last decades against a background of unchanged
blood alcohol legislation, with fatal accidents reduced
by 70%. However, the effectiveness of lowering the blood
alcohol limit to 0.5 mg/ml remains an unsettled issue.
In Canada, with a legal limit at 0.8 mg/ml, the death
rate of legally impaired drivers is almost three times
higher than in Germany, where the limit is 0.5 mg/ml
(Mayhew et al., 2002). Although geographical and cul-
tural factors might explain some of the differences,
Alcohol and Road Accidents 311
there is a growing support for lowering legal levels to
0.5 mg/ml in the EU.
Governments and specific organizations may play an
important role in curbing drink and drive problems. In
a few countries, diners are encouraged to appoint one
person the ‘designated driver’ by providing him/her
with a free meal and free non-alcoholic beverages, while
others are allowed to eat and drink as they please. In
other countries, a longer period of possession of the full
driving license is required, before permitting blood
alcohol limits 0.2 mg/ml. In Spain, a blood alcohol
limit of 0.3 mg/ml is set for inexperienced drivers, for
drivers of heavy goods vehicles, buses, and drivers of
vehicles carrying dangerous goods.
Some national databases report that riders of two-
wheel motor vehicles are less likely to drink and drive in
comparison to car drivers. On the basis of this observa-
tion, a lower limit would seem appropriate to reinforce
good riding behaviours instilled during training, since
very young riders (14 years) are only allowed to drive
low-powered two-wheel motor vehicles. For example,
alcohol limits were as low as 0.1 mg/ml for motorcy-
clists under 18 years of age in Austria and 0.2 mg/ml
for inexperienced drivers in the Netherlands (Peden
et al., 2001).
Large buses and goods vehicles constitute a specific
problem. Available statistics suggest that a large bus is
at higher risk of being involved in a road accident caus-
ing fatal or serious injury than a car, in relation to the
much greater passenger occupancy of buses and their
operation characteristics. The risk of accident for goods
vehicles is nearly the same as the one of cars, when nor-
malized per vehicle and per kilometre. However, large
vehicles involved in a crash may cause more severe
property damage, disruption, delay, and traffic conges-
tion especially in tunnels, on bridges, on main arterial
roads, or in densely populated urban areas. Therefore, a
uniform 0.2 mg/ml maximum level was adopted for all
drivers of large goods vehicles and buses, and some
operators have adopted a zero-alcohol policy for their
professional drivers (Peden et al., 2001). Such limits are
also recommended for drivers of vehicles carrying
dangerous goods.
The relationship between actual legal limits and the
incidence of drinking and driving behaviour is not
clearly understood. In the EU, drivers injured to death
with a blood alcohol concentration above legal limits
were estimated to be approximately 25% of the total. In
North America, where the legal limit is set between 0.8
and 1.0 mg/ml, the proportion is nonetheless higher,
and in Japan it is lower, with a limit of 0.5 mg/ml
since 1970.
Available evidence shows that a concerted effort to
reduce drink and drive behaviour is based on uniform
alcohol limits all over the EU, supported by specific
312 General Aspects of Pathology

national policies. All these actions are realistically departments suggest that alcohol is significantly asso-
attained to reduce the fatalities in events involving ciated with more severe injury or fatality, largely due
inappropriate drinking and driving by nearly 10% to the frequent association of alcohol drinking with
(Peden et al., 2001). This hypothesis is not scientifi- other host-related risk factors, such as high speed and
cally based, but represents a reasonable target, based misuse of restraint systems (Li et al., 1997).
upon international evidence. A reduction of about In a prospective cohort study, we studied 2354 adult
10% in road fatalities would save a total of 1000 lives injured patients consecutively admitted to an Italian
annually, corresponding to 2.5% of total fatalities due ED within 4 h from a road accident. We examined if a
to road accidents. About two-thirds of yearly saved positive blood alcohol concentration at the time of
lives would be drivers over the relevant blood alcohol crash (0.5 mg/ml), independently of any clinical evid-
limits and the remaining one-third would be sober ence and laboratory results indicating acute alcohol
drivers, vehicle occupants, and other road users. intoxication, was associated with specific features of
patients involved, specific types of injuries, and char-
acteristics of the accident. A blood alcohol concentra-
Alcohol and Characteristics of
tion 0.5 mg/ml was significantly more common in
Trauma Severity males, in young subjects, in subjects driving cars or
Several factors may add to alcohol to determine the risk trucks, and in persons involved in a crash during night-
of road accidents and the severity of injury (Commission time and at weekends. It was associated with higher
of the European Communities, 2003) (Table 1). trauma severity, but no differences were found in injury
The adverse effects of acute and chronic alcohol con- body distribution according to vehicle type. The preva-
sumption on psychological functions, safety behaviour, lence of injured patients with positive blood alcohol
and performance of driving subjects have long been increased from 17.2% in subjects aged 14–19 years
reported (Waller et al., 1986; Murray and Lopez, 1996). to a maximum of 25.7% in those aged 20–29 years,
Large clinical studies have been carried out to evalu- then declined progressively (P  0.001) along decades
ate the effects of alcohol intoxication on trauma severity of age to 9.5% over 60 years. Most subjects had
in patients after road accidents, with conflicting results. low-severity injuries, the category of the New Injury
Data from emergency department (ED) and police Severity Score (NISS) (Osler et al., 1997) ranging
from 1 to 3 in 1372 subjects, that is, over 50% of total
population. Multi-system trauma patients (NISS  16)
Table 1 Factors potentially adding to alcohol to determine the
risk of road accidents and the severity of injury were only 180 (7.6%), but 52 of these (28.9%) belonged
to the alcohol-positive group. Indeed, the prevalence
Road Injury of a positive blood alcohol concentration increased pro-
Risk factors accidents severity
gressively (P  0.001) along the classes of NISS, from
Males  14.4% in patients with a NISS  3 to a maximum of
Young people  30.8% in patients with NISS from 25 to 75. In a logis-
Night-time   tic regression analysis night-time, male gender, weekend
Weekend nights  
Inappropriate or  
nights, and age were independent factors predicting a
excessive speed positive blood alcohol concentration at the time of the
Insufficient experience  crash, whereas weekend and vehicle type had no sig-
of drivers nificant effects (Table 2). Night-time was the leading
Failure to use seat-belts   risk factor in both males and females, whereas other risk
or helmets
factors were weekend night for males and younger age
Misuse of child restraint 
devices for females. In multivariate logistic regression analysis,
Fatigue or sleepiness  the risk of a positive blood alcohol concentration in
Legal psychotropic or   injured patients at the time of crash was independently
illicit drugs associated with night-time [odds ratio (OR): 3.48;
Use of mobile phones
95% confidence intervals (CI): 2.46–4.91], male gender
Insufficient protection 
provided by vehicles [3.08 (2.36–4.01)], weekend nights [1.21 (1.05–1.41)],
High-risk accident dynamics   and age [0.92 (0.86–0.99) per decades]. No associa-
Non-compliance with driving  tion between positive blood alcohol concentration and
Poor visibility of other users,  the driver/passenger status was found, but the dynam-
or, insufficient field of vision
for the driver
ics of the crash was more frequently associated with
Older age  loss of control of the vehicle (bend road, vehicle went
off road) (Table 3). Only human factors, crash time,
Source: Commission of the European Communities (2003). and vehicle type have been considered as independent
 Alcohol and Road Accidents 313

Table 2 Dynamics of injury in 1245 injured patients involved in a car accident, in

relation to blood alcohol concentration (0.5 mg/ml).

Alcohol Alcohol
positive (%) negative (%) OR (95% CI) P value

Single patient 37.4 17.4 2.83 (2.02–3.98) 0.001

Extra-urban area 27.4 12.7 2.61 (1.94–3.51) 0.001
Bend road 44.6 14.5 4.77 (3.50–6.49) 0.001
Went-off road 39.8 13.0 4.42 (3.30–5.91) 0.001
Head-on collision 30.4 11.5 3.35 (2.49–4.51) 0.001
High-risk crash 36.0 16.2 2.92 (2.15–3.96) 0.001
No safety belts 12.8 27.1 0.40 (0.29–0.53) 0.001
No other vehicle 40.8 12.9 4.64 (3.47–6.22) 0.001
involved

Source: Data derived from Fabbri et al. (2002).

Table 3 Risk of positive blood alcohol concentration
(0.5 mg/ml) in patients involved in a road accident, in relation to
human variables, crash time, and vehicle type, tested by logistic
regression analysis
95% Confidence
Odds ratio intervals
Night-time 3.48 2.46–4.91
Male gender 3.08 2.36–4.01
Weekend night 1.21 1.05–1.41
Age 0.92 0.86–0.99
Note: Odds ratio was calculated considering night-time, gender,
and weekend night by dichotomous variables, age by decades.
Source: Data derived from Fabbri et al. (2001).
variables predicting an elevated blood alcohol concen-
tration, since most data regarding the type of crash and
number of subjects involved are difficult to classify
(Fabbri et al., 2002).
Age is considered an important risk factor for subjects’
impairment following alcohol-related crashes. Among
fatally injured drivers aged 26–35 years in 2000, 28%
had a blood alcohol concentration above the legal limit
of 0.8 mg/ml in Canada. Although the rate of involve-
ment in alcohol-related crashes among new drivers aged
16 and 17 years are similar to those among over 25,
younger drivers are three times more likely to die, per
kilometre driven (Mayhew et al., 2002).
Particularly noteworthy, adolescent girls are at high
risk of an alcohol-related death when male peers are
driving, compared with their peers as drivers (Quinlan
et al., 2000). Based on miles driven, the highest driver
fatality rates are found among the youngest and oldest
drivers. Compared with the fatality rate for drivers
aged 25–69, the rate for 16- to 69-year-old drivers is
about four times as high, and the rate for drivers aged
85 and older is nine times as high (Commission of the
European Communities, 2003). Among male drivers
younger than 21 years, a blood alcohol level of 0.2 mg/ml
more than doubles the relative risk for a single-vehicle
fatal crash. In this age group, girls have a relative risk
lower than boys at any blood alcohol concentration
(Zador et al., 2000). Such greater risk of young drivers
probably stems from a mix of overconfidence and lack
P value
of driving experience (Jonah, 1986). Also, the presence
0.001 of other teenagers in the car may encourage risky driv-
0.001 ing behaviours and is associated with increased fatal
0.009 crash risk among young drivers (Preusser et al., 1998).
0.034
Alcohol and driving does not constitute a risk factor
for older people; only a small proportion of old subjects
involved in a road accident have blood alcohol above
legal limits. In 1999, drivers aged 65 and older injured
to death in crashes were the least likely of any adult age
group to have a positive alcohol concentration. Their
crash risk per mile increases starting at 55 years and
exceeds that of a young driver by age 80, but is totally
unrelated to alcohol. In this age group, unsafe driving
is more dependent on factors associated with impaired
vision, attention, perception, and cognition (McGwin
et al., 2000).
Death of a child passenger transported by a drinking
driver is a very specific problem. In the United States,
crash databases of child passenger deaths indicate that
children are frequently unrestrained in the vehicle of a
drinking driver, typically a child’s parent or a caregiver
(Quinlan et al., 2000). Nearly 30% of the alcohol-
related child passenger deaths involve drivers younger
than 21 years, but old enough to be considered the
responsible care-taker rather than an adolescent peer
(Margolis et al., 2000). While the proportion of 14- and
15-year-old victims riding with drivers close to their
own age is high, the evidence of alcohol use in drivers
who were at least 6 years older than the child victim
highlights the need to modify the behaviour of these
responsible adults (Margolis et al., 2000).
Fatigue, especially when combined with alcohol, is
an additional risk factor. In a French national database
obtained from 1994 to 1998, crashes attended by police
314 General Aspects of Pathology
officers were categorized by a standard ministry ques-
tionnaire that covered time of accident, location, road,
and weather conditions, vehicles involved, mechanical
defects, health of driver, and alcohol consumption as
responsible of fatal events. Results showed that there
was a strong correlation between part of the day and
cause of crash, with most alcohol-related crashes occur-
ring at night-time. Fatigue, in particular when com-
bined to alcohol, was shown to be the main risk factor
for death or severe injuries (Philip et al., 2001).
Sleepiness is important as well. Drowsiness increases
crash risk and also alcohol concentrations of 0.1 mg/ml
may significantly increase susceptibility to sleepi-
ness and its adverse effects on driving performance
(Moskowitz and Fiorentino, 2000), but the additive
role of alcohol is not universally proved. Subjects given
low doses of alcohol following a night of reduced sleep
perform poorly in a driving simulator, even with no
detectable alcohol concentration (Roehrs et al., 1994).
In a New Zealand case–control study, a strong associa-
tion was observed between acute sleepiness of car driv-
ers and the risk of a crash in which a car occupant was
injured or killed, with an estimated proportion of car
crashes directly attributable to driver sleepiness ranging
from 3 to 30% of cases. The effect was not dependent
on acute alcohol consumption and other major con-
founding factors. In particular, driving while feeling
sleepy, driving after 5 h or less of sleep, and driving
between 2:00 and 5:00 a.m. were all associated with
an increased risk of injury and/or death after crash
(Connor et al., 2002).
Chronic alcohol consumption may also be consid-
ered. Subjects with blood alcohol concentration of
1.0 mg/ml were more likely than sober drivers to be
described as having markers of problem drinking. The
estimated percentage of fatally injured drivers who
were problem drinkers ranged from 21 to 61% among
those with blood alcohol concentration of 1.5 mg/ml,
and compared with patients only 1–7% in those with
zero blood alcohol concentration (Baker et al., 2002).
Physicians can play an important role in screening for
the prevention of repeated crashes in problem drinkers.
Specific questionnaires are sensitive tools for detecting
alcohol dependence, but may fail to detect abuse
(Knight et al., 2003). All patients of driving age, par-
ticularly those between 20 and 40 years repeatedly
involved in road accidents, should be screened for alco-
hol and drug abuse.
Illicit drugs may impair the severity of injury. Alcohol
and drugs of abuse in weekend drivers involved in road
accidents were measured in Belgium; almost half of
injured drivers had positive test results. Those with pos-
itive results for drugs or alcohol required more intensive
medical care than those with negative tests. A signifi-
cant proportion of drivers had positive drugs of abuse
independently of the presence of alcohol (Schepens et al.,
1998). Moreover, alcohol increases the sedative effects
of many common therapeutic agents, including benzodi-
azepines, narcotics, and some tricyclic antidepressant.
The presence of these drugs could potentially influence
the diagnosis and treatment of injured patients. Injuries
might be masked by the drug-altered mental state, and
treatment might be inappropriate in the presence of a
missed intoxication, for example, by sympathomimetics,
cocaine, phencyclidine and methamphetamines, car-
diovascular depressant, or opiates (Hernandez-Lopez
et al., 2002; Langdorf et al., 2003).
Most clinical studies on the association between alco-
hol and road accidents are, however, flawed by several
methodological issues. Crash characteristics are largely
different in relation to the type of vehicles and of sub-
jects involved (bicycle, motorcycle, car), or according to
the source of information (patients themselves, police
reports, emergency system personnel) (Muellerman
and Mueller, 1996). Several studies were hospital-based
or trauma centre-based, including patients in very
severe conditions; this policy increases the case-fatality
rate, but may conceal the importance of alcohol.
A few patients are sampled for alcohol measurement
at the crash scene, other have blood drawn in ED. Also
a blood alcohol concentration as low as 0.5–1.0 mg/ml
increases the risk of injury in road accidents in a
concentration-dependent way, and may continue until
blood alcohol is reduced to zero (Howat et al., 1991).
In a prospective study (Fabbri et al., 2002), we meas-
ured blood alcohol concentration in injured patients
after a road accident at time of ED admission, and cal-
culated the theoretical blood alcohol at time of crash by
reverse extrapolation, considering a mean rate of ethanol
elimination of 0.2 mg/ml/h (Gersham and Sleeper,
1991). In our experience, a sensitivity analysis per-
formed using a theoretical cut-off level of 1.0 mg/ml,
that is, in the toxic range, does not change the results
(Fabbri et al., 2002).
Several studies revealed that alcohol alters injury pat-
tern, resulting in more severe injuries from motor vehicle
crashes (Li et al., 1997). Bradbury (1991) showed that
alcohol-positive pedestrians involved in road accidents
had more severe and widespread injuries (more likely
facial injuries). Alcohol-intoxicated traumatized patients
have an increased probability of head injury and a
decreased probability of injury in any other body region
(Honkanen and Smith, 1991). In this setting, injuries are
more likely to occur in the head and face, and are usually
of low severity. Alcohol levels do not seem to influence
any other region of the body (Chen et al., 1999).
In an Italian study, nearly two-thirds of patients had
lesions either in the head and neck area, or in the extrem-
ities or pelvic girdle, without significant differences in
relation to blood alcohol concentrations (Fabbri et al.,

2002). In univariate analysis, no differences were found
in body distribution of injuries according to the type
of vehicle. An independent effect of alcohol on injury
type was not demonstrated, the main factor being
trauma severity.
The effects of alcohol on injury pattern are difficult
to determine. The altered risk perception, coupled
with reduced control of vehicle caused by alcohol, may
be important in determining the severity of injury.
Whether this is the result of alcohol-derived disinhibi-
tion, or simply stems from a behavioural pattern of sub-
jects prone to drink alcohol, is not known. In both
cases this results in a serious risk when driving (Chen
et al., 1999).
Alcohol-related injuries are a problem ‘largely invisi-
ble and poorly understood by public, the media and the
policy maker’. In a telephone audit, the public under-
standing of whether prevention strategies proved effective
is poor in United States of America. In this audit, nearly
75% of respondents endorsed the myth that alcohol
intoxication may be protective against an injury in the
event of a motor vehicle crash (Girasec et al., 2002).
As safety features are added to vehicles and roads, driv-
ers tend progressively to increase their exposure to colli-
sion risk, because they feel better protected. Improving
driving skills through advanced driving courses does not
lead to greater road safety. As long as safety measures
enhance driving performance, they also lead to greater
confidence, with confidence growing faster than skill,
resulting in overconfidence with higher risk driving
behaviours (Wilde, 2002). In a simulated computer test,
risk-taking behaviour people, when given feedback on
their decisions, adapt their decisions in relation to
changes in external danger, quickly learning to optimize
the risk they incur (Trimmpop, 1994). A comprehensive
study on the effects of vehicle modifications, laws on use
of seat belts, and reductions in drinking and driving
events proves that nearly 90% of this reduction is sim-
ply obtained by vehicle modifications (Robertson and
Drummer, 1994). A recent report suggests that the very
few cars awarded the top security score have a 36% lower
intrinsic fatal accident risk, compared to vehicles sim-
ply designed to meet the legal standards (Commission of
the European Communities, 2003). Clinicians might
counsel their patients regarding the dangers of driving a
motor vehicle under the influence of alcohol or other
drugs as well as for the risk of travelling in a vehicle oper-
ated by someone who is under the influence of other
substances of abuse. This counsel is most important for
high-risk patients.
Effects of Alcohol on Injury
It is controversial as to whether alcohol per se may influ-
ence the severity and outcome of the injured patient.
Alcohol and Road Accidents 315
Experimental studies suggest that alcohol may impair the
patho-physiological response to injury, but there is no
clear-cut evidence for an alcohol-injury severity relation-
ship, and the putative mechanisms are not definitely
proved (Li et al., 1997). Alcohol might act as a depressant
of the central nervous system and a peripheral vasodila-
tor. It has been shown that alcohol produces blunted
responses to haemorrhage by altering the haemody-
namic and the balance of lactic acidosis (Gruber et al.,
1992; Zink, 1998). After traffic injury, alcohol might
play a role in the homeostatic counter-regulation to
injury. The final outcome might depend by impaired
biochemical reactions or cell membrane damage. Both
chronic and acute alcohol abuse may lead to an altered
haemodynamic, metabolic, and cytokine response to
haemorrhagic shock, well demonstrated in experimental
animals (Phelan et al., 2002). The effects of acute ethanol
intoxication were also confirmed in an animal model of
simultaneous haemorrhagic shock and traumatic brain
injury in pigs (Zink, 1998). Animals pre-treated with
ethanol and submitted to standard procedures to incite
reproducible head injuries and to mimic haemorrhagic
shock displayed lower mean arterial pressures, lower cere-
bral perfusion pressures, and lower haemoglobin con-
centration. Alcohol-treated animals had shorter survival
times associated to higher cerebral venous lactate levels
and higher cerebral oxygen ratios. In summary, the detri-
mental effects of alcohol probably stems from impaired
cardiovascular function (Zink, 1998).
This animal experiment is supported by human data.
The presence of alcohol in injured patients may impair
cardiac conduction and metabolism, leading to cardiac
arrhythmias and hypotension. In a prospective study,
injured patients with alcohol intoxication had injuries
that caused more blood loss, more invasive monitoring,
more operative procedures, more fluid replacement, and
higher oxygen requirements (Sommers, 1994).
The effects might be mediated by altered circulating
and tissue cytokine responses to haemorrhagic shock,
indicating an imbalance in host-defence mechanism
leading to deleterious effects in the outcome of haemor-
rhagic shock (Phelan et al., 2002), in which several fac-
tors might contribute to. First, a direct depressive effect
of alcohol on the myocardium must be considered, as
well as a relative hypovolaemia secondary to the diuretic
effect of alcohol, mediated by an inhibitory mechanism
on the release of vasopressin and free water diuresis
(Albin and Bunegin, 1986; Dickmen et al., 1995).
Second, high blood alcohol levels may cause signifi-
cant changes in the acid–base status with a greater base
deficit in alcohol intoxicated trauma victims. When
acidosis develops it is most likely to occur via tissue
hypo-perfusion and anaerobic metabolism, expressed
by an increase in circulating lactate levels (Davis et al.,
1997; Dunham et al., 2000).
316 General Aspects of Pathology
Third, alcohol may influence the cytokine response
to haemorrhagic shock. It markedly blunts serum
tumour necrosis factor (TNF)-
levels in rats (Nelson suspicion of skull fracture. This inequality generally dis-
et al., 1989), whereas haemorrhage enhances cyto-
kine expression during early post-resuscitation period
(Molina et al., 1997). In a recent study, alcohol intoxi-
cation blunted the haemorrhage-induced increase in
circulating TNF-
levels, with increased TNF-
severity of injuries, making the management of indi-
expression in the lung. The mechanism(s) responsible
for this upregulation is not known, but could be the
result of an altered cytokine processing (Zhang et al.,
2000). Circulating levels of interleukin (IL)-6 are
reduced in injured rats pre-treated with alcohol (Rivier,
1999), but in a burn injury experimental model, alco-
hol produced an upregulation of circulating and hepatic
levels of IL-6 with contrasting effects (Colantoni et al.,
2000). This upregulation in IL-6 production after
trauma might be nonetheless detrimental and con-
tribute to the generalized immune suppression syn-
drome, clearly documented in alcohol injured cases
(Fontanilla et al., 2000). Other studies suggest an
upregulation of lung IL-6 after haemorrhagic shock
and fluid resuscitation, contributing to long neu-
trophil recruitment and lung injury (Hierholzer et al.,
1998; Meng et al., 2001). In experimental models,
only a stimulatory effect of alcohol on IL-10 expression
was observed, with an increased release from mono-
cytes (Mandrekar et al., 1996) and an inhibitory effect
of the inflammatory cascade with immunosuppressive
effects (Karakosiz et al., 2000).
Finally, alcohol might alter the hepatic metabolism
of several drugs, with a cross-tolerance effect. The meta-
bolism of psychoactive drugs, as well as anaesthetics
cleared by the liver, might be accelerated in patients
with chronic alcohol abuse, and doses may be adjusted
to maintain standard effects (Fraser, 1997). This topic
is dealt with in different chapters.
Effects of Alcohol on Outcome
after Injury
Large clinical studies evaluated the effects of alcohol
intoxication on morbidity and mortality after road
accident, with conflicting results.
In an historical paper, it was cited that ‘the alcoholic
concentration of the urine, breath or body tissues con-
stitutes the most reliable single factor in arriving at a
correct diagnosis of the degree of acute alcoholic intoxi-
cation of a patient’. It was observed that in patients with
alcohol intoxication consciousness was altered and that
in most cases it was impossible to determine whether
and to what extent the altered sensorium was affected
by trauma or by the pharmacological effects of alcohol.
In suggesting that quantitative testing for alcohol in
such cases could be extremely useful in the differential
diagnosis, it was noted that unequal pupils were encoun-
tered in more than a dozen patients, often giving rise to a
appeared as the patients became sober (Bogen, 1928).
Nearly 75 years of experience has not changed the
validity of this conclusion. Both acute ingestion and
chronic abuse of alcohol increase the frequency and
vidual patients difficult, in particular in the presence
of head trauma. The presence of alcohol may also
interfere with the accurate and rapid diagnosis of
intra-abdominal injuries, causing circulatory collapse,
reducing immune response, altering hepatic metabo-
lism, or stimulating delirium tremens (Waller, 1990). A
proper management of an injured patient with alcohol
includes blood alcohol determination, careful history-
taking for alcoholism with referral for further evalua-
tion or treatment when indicated, and detection of
illicit drugs (Waller, 1990).
Alcohol-intoxicated patients are considered ‘pharma-
cologically modified’ by a potent respiratory, cardiovas-
cular, and central nervous system depressant (Chang and
Astrachan, 1988). In particular, intoxicated and injured
patients are frequently judged at first evaluation to have
more severe injuries than they actually have. The impli-
cations are that the clinical judgement might overestim-
ate the degree of injury, prompting a greater number of
diagnostic manoeuvres than in non-intoxicated patients
with similar injuries (i.e. immediate tracheal intuba-
tion, diagnostic peritoneal lavage, head computed tomo-
graphy, intracranial pressure monitoring procedures)
(Jurkovich et al., 1992). Early knowledge of blood alco-
hol levels is important to reduce the use of invasive pro-
cedures in the first evaluation in the ED.
Despite the ability of alcohol to produce a broad
range of adverse effects on several organ systems, the
consequences of alcohol intoxication on mortality and
morbidity are not definitely proved. Acute alcohol
intoxication per se is not likely to prevent or to enhance
mortality or morbidity following injury from road acci-
dent (Li et al., 1997), but whenever behavioural and/or
biochemical evidence of chronic alcoholism is present,
an increased risk of complicating events during hospi-
talization is well proved (Jurkovich et al., 1993).
Intoxicated patients with head injury are more likely
to be intubated in the crash scene or in the ED, to
require an intracranial pressure monitoring, to develop
respiratory distress necessitating ventilator assistance,
or to develop pneumonia (Gurney et al., 1992). How-
ever, in a prospective study of injured patients after
road accident, acute alcohol intoxication had no effect
on the risk of dying within the first 24 h from hospital
admission, after the first 24 h, or overall. Acute intoxi-
cation did not increase the risk of complications, and
was associated with a shorter length of stay. Only

Table 4 Risk of mortality and expected permanent disability in trauma patients
after road accidents in relation to positive blood alcohol concentration (0.1 mg/ml)
Alcohol
Prognostic positive,
outcomes n  446
Mortality 8 (1.8%)
Expected disability 23 (5.2%)
Mortality or expected 30 (6.7%)
disability
Source: Data derived from Fabbri et al. (2001).
patients with biochemical and behavioural evidence
of chronic alcohol abuse had a twofold increased risk
of infective complications, particularly pneumonia
(Jurkovich et al., 1993).
In a 25-year follow-up study, the association between
drunk driving and/or risky driving offences and subse-
quent hospitalization was studied. Information about
drinking habits and psychosocial factors for 8122 con-
scripts from the Stockholm County in 1969–70 was
linked to register data on hospitalization, mortality
drunk driving, and risky driving. The results show a
significantly increased risk of hospitalization and mor-
tality both in the drunk driving and in the risky driving
groups (Karlsson et al., 2003).
We examined if a positive blood alcohol concen-
tration, even in a non-toxic range, affects management
and outcome of injured patients after road accident
in a prospective cohort study, recruiting all adult sub-
jects admitted to an ED within 4 h after a road acci-
dent (Fabbri et al., 2001). Outcomes were mortality or
expected permanent disability, and data related to
patients’ treatment and hospital course. In the final
cohort of 2354 adult injured patients, 446 (18.9%) had
a positive (0.1 mg/ml) alcohol concentration at the
time of ED evaluation [mean (SD): 0.89 (0.71) mg/ml],
but only 123 (5.2%) had toxic concentrations exceed-
ing 1.0 mg/ml. Clinical evidence of alcohol intoxica-
tion was present in only 108/446 cases, corresponding
to 24.2% of all alcohol positive patients.
A total of 27 patients (1.1%) died as a direct conse-
quence of road accident. Eleven died within 24 h dur-
ing treatment in the ED, notably six cases for severe
head injury, four cases for high-grade chest lesions,
one patient for pelvic girdle injury, and the remaining
16 patients during hospital stay. Patients who died had
more severe injuries, irrespective of pre-existing medical
conditions. Expected permanent disability was mainly
related to injuries of the nervous system. A large pro-
portion of these patients had severe head or neck
(47.6% of cases), thoracic (29.8%), or abdominal
(6.0%) injuries. Severe injuries of the extremities were
present in 36.9% of cases and predominantly affected
the lower limbs.
Alcohol and Road Accidents 317
Alcohol
negative, Odds ratio
n  1908 (95% CI) P value
19 (1.0%) 1.82 (0.79–4.17) 0.161
61 (3.2%) 1.65 (1.01–2.69) 0.047
79 (4.1%) 1.67 (1.08–2.58) 0.021
Mortality was not significantly increased in the
presence of a positive blood alcohol. However, when
mortality and expected permanent disability were
cumulated, the final risk increased in alcohol-positive
patients (Table 4).
The prevalence of critical patients at time of transfer
from ED to surgical or ordinary wards was also signific-
antly larger. Alcohol-positive patients were more likely to
need intensive care, surgery, blood transfusions, and hos-
pitalization for more than 1 week. Length of stay largely
varied (median 5 days; interquartile range 2–9 days) and
was extremely long for those patients who experienced
pneumonia or septicaemia (up to 127 days). Alcohol-
positive patients also had a larger incidence of acute
medical complications, in particular infections, respira-
tory failure, and shock (Table 5).
In 236 patients (10.1%), an injury, unsuspected at
first evaluation, was diagnosed only at final evaluation,
possibly due to the confounding effects of alcohol on
patients’ sensorium. Such injuries, usually not life-
threatening, were approximately fivefold more common
in patients positive for blood alcohol concentration
[113/442 (25.6%) versus 123/1901 (6.5%) in alcohol-
negative patients; OR 4.96, 95% CI 3.75–6.58;
P  0.001], with differences in the injury body–area
distribution. In particular, head and neck injuries (usu-
ally low grade), face, chest, and extremities or pelvic
girdle content injuries were more common in alcohol-
positive patients.
The prevalence of cases with unsuspected injuries
was associated with co-morbidity and trauma severity
(P  0.001). When the presence of unsuspected injuries
was tested as dependent variable in multivariate analy-
sis, the categorized NISS (OR 2.62; 95% CI
2.30–2.98; P  0.001), alcohol (OR 4.98; 95% CI
3.62–6.87; P  0.001), and co-morbidity (OR 2.19;
95% CI 1.54–3.11; P  0.001) were independent risk
factors. An alcohol-positive patient might thus alert
the physician that additional, non-easily detectable
lesions are likely to be missed, and that a more careful
evaluation is needed before any final decision.
On the basis of the coefficients computed by the logis-
tic regression, a risk score for developing unsuspected
318 General Aspects of Pathology
Table 5 Risk of management problems in injured patients after road accidents in relation to positive
(0.1 mg/ml) blood alcohol concentrations
Management Alcohol positive,
outcomes n  442a
Intensive care unit 15 (3.4%)
Surgery 56 (12.7%)
Blood transfusions 19 (4.3%)
Length of hospital 57 (12.9%)
stay (7 days)
Acute complications 41 (9.3%)
Any infection 26 (5.9%)
Respiratory failure 13 (2.9%)
Shock 15 (3.4%)
a
Patients surviving at least 24 h following emergency department admission.
Note: 95% CI indicates confidence intervals.
Source: Data derived from Fabbri et al. (2001).
injuries was calculated as the sum of the categorized
NISS, blood alcohol levels, and co-morbidity. The
accuracy in predicting unsuspected injuries, based on
the receiver operator characteristic (ROC) curve was
0.862  0.012 and a score value less or equal to 2 (best
cut-off ) had a sensitivity of 87.7% and a specificity of
69.4%. To quantify the specific contribution of alco-
hol levels in identifying patients with unsuspected
injuries, the ROC curve obtained by logistic regres-
sion analysis using the sole NISS and co-morbidity
was also calculated. Excluding alcohol, the accuracy
significantly decreased to 0.813  0.015 (P  0.001)
and the sensitivity and the specificity at the optimal
operating point of the curve were 68.6 and 81.4%,
respectively.
Comparing the two ROC curves at the same sensi-
tivity value of the best cut-off, the exclusion of blood
alcohol concentration significantly reduced the speci-
ficity to nearly 60% (Fabbri et al., 2001). In conclu-
sion, it is unclear to what extent alcohol intoxication
affects the hospital course of trauma patients or affects
decision-making of physicians in diagnosis and treat-
ment of trauma patients. The confounding effect of
alcohol may be different in relation to injury severity.
In low-severity patients, symptoms are the key points
for diagnostic assessment. In these cases, the risk of
secondary lesions is increased by the confounding
effect of any measurable blood alcohol concentration.
By contrast, patients with major trauma are currently
assessed by advanced trauma life support criteria and
minor injuries of chest and extremities might be
ignored at initial evaluation, to care immediately for
more severe, life-threatening injuries. In these patients,
the risk of additional lesions is expected to be high,
also in the absence of recent alcohol intake. The finding
that additional injuries are more likely associated with
the presence of alcohol also in these severe patients
Alcohol negative, Odds ratio
n  1901a (95% CI) P value
35 (1.8%) 1.87 (1.01–3.46) 0.045
134 (7.0%) 1.91 (1.37–2.66) 0.001
40 (2.1%) 2.09 (1.20–3.64) 0.009
182 (9.6%) 1.40 (1.02–1.92) 0.038
95 (5.0%) 1.94 (1.33–2.85) 0.001
63 (3.3%) 1.82 (1.14–2.91) 0.012
27 (1.4%) 2.10 (1.08–4.11) 0.030
35 (1.8%) 1.87 (1.01–3.46) 0.045
might simply depend on the primary association of
alcohol with injury severity.
Chronic Alcohol Abuse and
Road Accidents
A final specific problem regards the relationship of
chronic alcohol abuse and road accidents. Intoxicated
patients have similar hospital and ED recidivism rates
for road accidents independently of driver or passen-
ger status (Shermer et al., 2001), but intoxicated driv-
ers are involved in more crashes, need more health care
resources, and are at increased likelihood of death after
a traffic injury (Waller et al., 1986). In a comprehen-
sive review of studies (Vingilis, 1983), although most
alcohol-positive drivers were initially considered social
drinkers, subsequent evidence suggested that 30–50%
of drivers with alcohol-related crashes or citations have
drinking problems. Recent studies of drinking prob-
lems among drivers admitted because of road acci-
dents report that about 18% of them meet criteria for
current alcohol dependence (Sodestrom et al., 1997).
Both periodic binge drinking (more than five drinks
on an occasion) as well as chronic heavy drinking appear
to independently contribute to driving while intoxi-
cated (Duncan, 1997; Duncan et al., 1999). Drinking
drivers, involved in a crash in which their child passen-
ger died, have been observed to be over six times more
likely than non-drinking drivers to have prior convic-
tions for driving while impaired (Quinlan et al., 2000).
Fatally injured US drivers were recently studied to
examine the relationship between blood alcohol data
from crash reports and a history of problem drinking,
based upon interviews with family members. The
results show that drivers with very high alcohol levels
were far more likely to be described as problem drinkers
than other fatally injured drivers, whereas only a small

percentage of drivers without detectable blood alcohol
had markers for problem drinking (Baker et al., 2002).
Physicians who provide care for injured patients after
road accidents have an important role in preventing
alcohol-related injury and death (Todd. 1997). A pre-
vious road accident and injury per se does not change
driving behaviour, but structured interventions are
effective. Physicians can refer patients suspected for
drinking and driving for treatment at any time and
their motivation may be increased after a road accident.
In a follow-up study, alcohol-positive drivers were more
likely to be readmitted to the ED for crash recidivism
than non-drinker drivers (McLellan et al., 1993). Brief
interventions in the emergency room decrease alcohol
consumption and decrease the incidence of further
events caused by driving under the influence of alcohol
(Monti et al., 1999).
Conclusions
Actions to promote road safety entail extremely low
costs compared with the human, social, and economic
burden of road traffic injuries. Positive blood alcohol
concentrations account for a large proportion of these
costs, and any attempt to reduce drinking and driv-
ing behaviours is highly effective. National strategies
to implement recommendations and actions of EU
Commission on alcohol limits are urgently needed.
Results derived from experimental and clinical studies
reinforce the concept that alcohol has deleterious effects
on all phases, both preceding and following road acci-
dents; it may exacerbate independent risk factors and
risky behaviours, leading to crash, as well as injury
severity, complications, and final outcome. Thousands
of lives could be saved in the EU simply by reducing
alcohol-related events. Physicians have the important
task to contribute to national actions towards safer
behaviours, to improve compliance with the existing
legal limits of blood alcohol, to advice road users on the
personal and social risk of drinking and driving, and,
finally, to help governments to allocate resources for
enforcement and deterrence.
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